University Of Washington Claim Form Page 3

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Name, address, and telephone number of treating physician (attach medical reports and billings):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I/We submit that I/we have read the foregoing and submit that the information contained therein is true and correct to
the best of my/our knowledge.
1st Claimant’s signature: _________________________________________
Date: _______________________
2nd Claimant’s signature: _________________________________________
Date: _______________________
3

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